bennett bigelow leedom, p.s. zui] oc1~ · appropriate care, or ofpaying co-insuranceor the like,...

LAW OFFICES

BENNETTBIGELOW& LEEDOM, P.s. ~

ZUI] OC1~ <:j: IbMichael Madden

AttomeyH~ c·.'·;:'h\llllldtlen@1:llJIlaw.com

f--'; -.~

Cl·j~i H":"-:;':~ClC::-i,":~r

Via Legal Messenger

Honorable Mike KreidlerOffice ofthe Insurance CommissionerHearings Unit5000 Capitol Blvd. SETumwater, WA 98501-4426

Re: Demand for Hearing .

. Dear Mr. Kreidler:

October 22, 2013

Our finn represents Seattle Children's Hospital (SCH),a Washington not-tor-profitcorpora.lion, which operates a licensed pediatric hospital in Seattle. SCH submits this demand forhearing under RCW 48.04.010(1)(b) and RCW 34.05.413(1) to challenge the decisions by theOffice of the Insurance Commissioner approving the following individual market Exchange raterequest filings:!

Carrier Date of OIC Decision ReQuestID # Attachm(J~

Coordinated Care Corporation September 5, 2013 259755 AMolina Healthcare ofWashington, Inc.

--September 4, 2013 259759 B

Premera Blue Cross July 31, 2013 254695 CBridgespan Health Company July 31,2013 254781 D

SCH is aggrieved or adversely affected by the OlC's approvals. SClI is the only pediahichospital in King County and the preeminent provider of pediatric specialty services in theNorthwest. Many of these services are not available elsewhere in the Northwest. None of thesefour OlC-approved Exchange plans has contracted with, SCH to provide services to planparticipants. As a result, cun'ent and future SCU patients and families who obtain insurance in theseExchange plans for their ongoing care will not be able to access care at SCH as an in-networkprovider. Because of the absence of appropriate access to pediatric services in these networks,

I Copies of excerpted portions of these decisions are attached as noted in the chart.

GOt'Unlon Street, Suite 1500SQattle, Washington 98101·1363

T 206.622.5511F 206.622.B986

BBLLAW.COM

Hon. Mike KreidlerRe: Seattle Children's Hospital Demand for HearingOctober 22, 2013

children and families enrolled in these plans will be faced with the choice of not receivingappropriate care, or of paying co-insurance or the like, if they do. Many patients enrolled in theseexchange plans who require services available only at SCH are likely to present for services at SCI-I,regardless of its network status, more acutely ill and require more services, and more complexservices when tlley present for care. These patients will consmne more resources, thereby reducingresources available for other SCH patients and impahing the ability of SCH to serve the pediatrichealthcare needs of the region. SCH will, in addition, not be fairly compensated for these servicesbecause of its exclusion from these exchange plan networks. In these and oth~T ways, ()lC's actionshave prejudiced SCH and its patients. The interests of SCI-! and its paticnts are among those that theOlC was required to consider when it reviewed these Exchange plans, and a hcaring decision infavor of SCI-! can substantially eliminate or redress the prejudice caused by the OlC's tinalapprovals.

SCH requests relief for the following reasons:a. The OIC failed to require these carriers to submit complete and accurate infonnation

which would enable the OlC to render a fully-infonned and legally supportable decision on the raterequest filings.

b. The OlC based its decision upon incomplete, insufficient, inaccurate, andinconsistent infonnation.

c. The OlC failed to follow proper statutory and regulatory procedures applicable toreviews of rate request filings, including, but not limited to, failing to consider the inadequacy ofthese carriers' provider networks, which do not include SCH.

d. The rate request filings were incomplete, insufficient, inaccurate, and inconsistent.e. The record does not establish tllat the rate request filings. satisfy the network

adequacy review criteria set forth in WAC 284-43-200.f. The OIC's apparent findings with respect to network adequacy are incorrect, not

adequately supported by evidence, and/or not made in accordance with applicable law.g. The OIC's decisions were not rendered in accordance with the substantive and

procedural requirements of RCW Chapters 48.43 and 48.44, WAC Chapter 284-43, RCW Chapter34.05, and other applicable statutes and regulations.

h. The OIC's decisions werc not in compliance with 42 U.S.C. § l8031(e)(1)(C),which requires qualified health plans to include within their plan networks "essential communityproviders," as defined to include SCI-I, and other applicable federal laws and regulations.

i. The OIC's decision approving the CCC Exchange plan, which includes the use of"spot contracting" or "single payor agreements" to complete its network of providers, is not inaccordance with applicable statutes and regulations.

SCH asks the OlC for relief regarding the decisions approving these Exchange plans in oneor more ofthe following ways:

Hon. Mike KreidlerRe: Seattle Children's Hospital Demand for HearingOctober 22, 2013Page 2

• Reconsideration of the decisions;• Imposition of a stay ofthe decisions;• Revocation or reversal of its decisions;• Such other and further relief as this tribunal may grant under its authority.

Our contact infonnation is:

Mike MaddenCarol Sue JanesBennett, Bigelow & Leedom, P.S.60 I Union Street, Suite 1500Seattle, WA 98101(206) [email protected]@bbllaw.cdlTI

Very truly yours,

MMlCSJ:

cc: Coordinated Care CorporationMolina Health Plan ofWashington, Inc.Premera Blue CrossBridgespan Health CompanyAnnaLisa Gellennan, Deputy Commissioner for Legal AffairsMarta DeLeon, AAG

{0766,OOOOOIM0897837.DOCX; 2)

Attachment A

SERFF Tracking'#: CELT-129184888 Stat. Tracking #: 259755 Company Tracking/I: 61836WAOOI-RATE

State: Washfngton FlIlng Company: Coordinated Cere CorporationTOI/Sub-TOI:. HOrg021 Individual Health Organllations· Health Maintenance (HMO)/HOrg02/.00f5C lnd{v/duB/.~ OtherProduct Name: AmbetterProject Name/Number: 161836WA001-Rate

Filing at a GlanceCompany:

Product Name:

State:

TOI:

Sub-TOI:

Filing Type:

Date Submitted:

SERFF Tr Num:

SERFF Status:

State Tr Num:

State Status:

Co Tr Num:

ImplementationDate Requested:

Author(s):

Revlewer(s):

'Disposition Date:

Disposition Status:

Implementation Date:

State Filing Description:

Coordinated Care Corporation

Ambetter

Washington

HOrg0211ndividuai Health Organizations - Health Maintenance (HMO)

HOrg021.005C Indlvidual- Other

Rate

08/30/2013

CElT-129184888

Closed-Flied

259755

Flied

61836WA001-RATE

, 01/01/2014

Daniel Martinez,Ashley Schute, lauren Re9nery, Jane Neal, Tracey McMillan, Susan Kohler,Sara Ross

Lichlou lee (primary)

09/05/2013'

Filed

01/01/2014

POF Pipeline for SERFF Tracking Number CELT-129184888 Generated 09/12/2013 06:03 PM

· _ ""'_, 'U'''''~''''''~~_'''''''"''

SERFF Tracking #: CEL T-129184888 Stal. Tmcking #: 259755 Company TrackIng #: 61836WA001~RATE

State: Washington Fifing Company: Coordinated Care Corporation

TOVSubw TOI: HOrg02/ 'ndividual Health Organ{zatfons ~ Health Maintenance (HMO)/HOrg02J.O05C Individual· OtherProduct Namo: AmbetterProject Name/Number: At1836WA001~Rate

General InformationProject Name:

Project Number: 61836WA001·RateRequested Filing Mode: Review & Approval

Explanation ior. Combination/Other:Submission Type: New SUbmission

Overall Rate Impact:

Deemer Date:Submitted By: Sara Ross

'PPACA Notes: null

Exchange Intentions:

Filing Description:

Re: 'Coordinated Care CorporationNAIC N().: 95831FEIN: 39-1821211

Status of Filing in Domicile: Pending

Date Approved in Domicile:

Domicile Status Comments:Market Type: Individual

Individual Market Type: IndividualFiling Status Changed: 09/05/2013Stat~ Status Changed: 09/05/2013

Created By: Sara RossCorresponding Filing Tracking Number:

PPACA: Non-Grandfathered Immed Mkt Reforms·

Exchange Only

INDIVIDUAL HMO "EXCHANGE" MAJOR MEDICAL PLAN - RATE FILINGForm 61836WA001 - Individual HMO Policy-SERFF Tracking #CELT-129184979Form 61836WA002 -Individual HMO Policy-SERFF Tracking #CELT-129184991Form 61836WA003 - Individual HMO Policy-SERFF Tracking #CELT-129184921Schedule of Benefits

McHugh Consulting.Resources, Inc. has been requested to file the rates on behalf of Coordinated Care Corporation. We haveprovided a letter of authorization for your files.

The attached rates are being submitted to your Department for review and ·approval. At the request of the Washington Office ofthe Insurance Commissioner, we are submitting the captioned product and plans offered from Coordinated Care to be .marketed and sold on the Health Benefits Exchange in Washington. In addition, Coordinated Care will partner wilh localcommunity outreach programs and advocacy groups to provide an understanding of the marketplace and how the CoordinatedCare products will fit their needs.

Rate Filing Instructions - iBenefit Plan --- Metal Level ·-Actuarial Value61836WA0010002--- Gold----- 78.26%61836WA0020002-- Silver---·- 68041 %61836WA0020002-04·-- Silver 73%---72.89%61836WA0020002-05--· Silver 87%·--87.12%61836WA0020002·06--- Silver 94%---93.66%61836WA0030002·-- Bronze--- 60047%

Items ii and iii on the Rate Filing instructions are N/A ior this product, as it is a new product filing.

PDF Pipeline forSERFF Tracking Number CELT-129184888 Genamlad 0911212013 06:03 PM

SfiRFF TrackIng #: CE'LT-129184888 . State Tracking #: 269765 Company Tracking #: 61836WA001·RATE

Stato: Washington filing Company: Coordinated Care CorporatfonTOVSub~ TOI: HOrg021lndividual'Health Organizations ~ Health MEl/nt.finance (HMO)/HOrgV21.006C Individual -OtherProduct Name: AmbetterProject Name/Number: /61836WA001-Rare

If you have any questions, please feel free to contact me at the phone number or e-mail address listed below. Thank you for.your consideration, we look forward to your favorable review.

Sincerely,

McHugh'Consulting Resources, Inc215-230-7960mcr@mchughconsulting,com

Attachments

Company and ContactFiling Contact InformationDaniel Martinez, Contract Analyst233 S, Wacker Dr, Suite 700Chicago, IL 60606·6393

Filing Company InformationCoordinated Care Corporation7700 Forsyth BlvdSt.Louis, MO 63105(314) 725-4477 ext. [Phone]

[email protected] [Phone]312-441-0822 [FAX]

CoCode: 95831Group Code:Group Name:FEIN Number: 39-1821211

State of Domicile: indianaCompany Type:State 10 Number:

---------------------_.•_--------'----,-_._._--~----'

Filing FeesFee Required?

Retaliatory?

Fee Explanation:

No

No

State SpecificIf you are filing a Healthcareor Disability filing, Is the Co Tracking # field populated on the General Information Tab? If no,your filing will be rejected, (yes/no): YesFonm Tab Only - Are the Form # and Form'Description fields populated corresponding to the attached form? (yes/no): N/AIf your are submitting a File and Use produot, have you populated thelmplementalion Date field? (yes/no): No

PDF Plpel;ne for SERFF Trecklng Number CELT-129184888 Generated 0911212013 06:03 PM

SERFF Tracking #:. CEI.T-129184888 State Trackirig #: 259755 Company Tracking #: 61836WA001-RA7E

Washington RUng Company: CoorOInated Care Corporation

HOrg02f fnaf'liduaf Health Organizations - Health Maintenance (HMO)/HOrg021.00SC IndiVidual - Other

Ambetter

161836WAOO1~Rate

Stale:TOUSutrTOI:

Product Name:

Project Name/Number:

. -~--------~'.'" .._,-,--~-_ ..-~ _. __.,- ~ -------- ----._--_.----.----_._.._-_.

----._..- ._---

Correspondence Summary.O-is-P-QS.ltiQOl>_ ._!Status

,Filed

A!D~.rul.m.e.nj~L _Schedule....._........_----Supporting

Document-

Created By. ...

Lichiou Lee

Schedule Item Name

Rate Attestation

.._. ._.. __ 'Created On. ._

09/05/2013

. .__. Created By

Daniel Martinez

-Created On

09/0412013

Date Submitted--.------ --

09/05/2013

Date Submitted- _......~"-_ ..,.- ,

09/0512013

'Supporting

Document

.. Unified Rate Review Template Sara Ross 09/03/2013 09/0312013

E'iling.NQtel>

SU!'ie_cot..

P"rt I RequirerlJ"nt

Control Sheet

R>li:"B"..q.ll,,~t Summary

Rate.R",\uest Decision

.Note Type- ......._ Created By Created On Date Submitted"-.~..~,_.' .. -.', .'

Note To Filer Nikki Meador 09/0312013 0910312013... ----- ..__.._..__..__._.. - _...~._-_.~~ .

Reviewer Note Kelli Armfield 0911212013...... .<"

Reviewer Note Kelli Armfield 09/1212013_..•____--,,-_._- ---"',

Reviewer Note Kelli Armfield 09/1212013

PDF Pipeline for SERFF Tracking Number eELT-129184888 Generated 09(1212013 06:03 PM

Washington" Rfing Company: Coordinated-Care Corporation

HOrg021lndMdual Health Organizations - H~aJth Maintenance (HMO)/HOrg021.005C lndividuaf· Other

Ambet1er/61836WAOO1-Rate

SERFF Tracking #:

State:

TOr/Sub-TO/:

Product Name:


Disposition

CELT-129184888 State Tracking #: 259755 Company Tracking #: 61836WAOO1-RA1E

---_._---_.. _.

Dispo?ition Date: 09/05/2013

Implementation Date: 01/01/2014

Status: Filed

HHS Status: HHS Approved

State Review: Reviewed by Actuary

Comment: This fHing is filEld as the rates are the same as previously submitted under the state tracker ID 257060.

Coordinated Care New Product 0.000%·Corporation

Percent Change Approved:

Minimum:

Maximum:

Weighted Average:.

Maximum % Minimum %

Change Change

(where req'd): (where req'd):

Company

Name:

Company

Rate

Change:

Overall %.

Indicated

Change:

Overall %

Rate

Impact:

0.000%

Written

Premium

Change for.

this Program:

$0

#of Policy

Holders Affected

for this Program:

o

%

%

%

Written

Premium for

this Program:

:$0 0.000% 0.000%

Schedule

Supporting DoclJrnent

Supporting Document

Supporting Document (revised).

Supporting Document

Supporting Document

Supporting DOcument

Supporting Document

Schedule Item

Acluanal Memorandum and Certifications

Consumer Disclosure Form DeScriptions

Unified Rate Review Template


WA FHing Summary

.SERFF Authorization Letter

Rate Formula

Schedule Item Status Public Access

Yes

Yes

Yes

Yes

Yes

Yes

Yes

PDF Pipeline for SERFF Tracking NumberCELT-129184888 Generated D9/12i2013 06:03 PM

· SERFF Tracking #: CELT-129184888 State Tracking #: 259755 Company Tracking #:

------_._.61838IMlOO1-RATE

State: .

TOlISub-TO/:

Product Name:

Project NamelNumber:

Washington Filing Company: Coordinated Care Corporation

HOrg02ilndividual Health Organizations - Hea1U1 Maintenance (HMO)/HOrg021.005C Indivk!ual- Other

Ambetter

161836WA001-R?te

Schedule

~1l.!'_(J.':lrti__n_~_~~Ell_rnent .__

-~.u_(JR°rtin(ilDocurn~'!t ._. _

-Rate

'Rate

Schedule Item.............._."."_.,,.

_1:)~LectionlDisafJfJrovaIResponseMaterials .

Rate Attestation

Rate Schedule

Counties

Schedule Item Status..""..".'--'..••'.'..'--'-'- - Public Access.__......_.....__ ...._.-

Yes

Yes

Yes

-Yes

PDF Pipeline for SERFF Tracking Number eELT-129184888 Gene-rate9 0911212013 06:03 PM

Washington Filing Company: Coordinated Care Cotporation

HOrg02IlndividuaJ Health Organizations - Health Maintenance (HMO)/H0rg02J.OO5C lndividual- other

Ambetter/fj1836WA001-Rate

--~---~-------~

SERFF Tracking fI:

St<te:TOUSub·T01:

Product Name:

Project NamefNumber:

CELT-129184888 State Tracking #: 259755 Company TraCking #: 61836WAOO1-RA7E

Amendment Letter

Submitted Date: 09/0512013

Comments:

Attached please find Coordinated Care's Executive Attestation~

Changed Items:

No Form Schedule Items Changed,

No Rate Schedule Items Changed~

20130904RateAtleslatior':~[)f

:Rate AttestationCommenta:

Attachment(s):

~upportinaP_()~cumentSch'CcllJ~~e~.!!~':".~~h~,,!,~es__SatisfieCl - Item:

PDF Pipeline. for SERFF Tracking NumberCELT-12918~888 Generated 09/12/201306:03 PM

Washington Filing Company: Coordinated care Corporation'J-fOrg021Individuaf Health Organizations - Health Maintenance (HMO)/HOrg021.00SC IndMdual- Other

Ambetter

J51836WA001-Rate

SERFF Tracking #:

State:

TOUSub-TOI:

Produq Name:


CELT-129184888 State Tracking #: 259755 Company Tracking #: 61836WA001-RATE

--------------

-Amendment Letter

Submitted Date: 09/03/2013Comments:

Coordinated Care has amendedthe fiiing to include the correct naming conventions tor the Rate Review Template_ Part I Unifified Rate Review Data Tempiate_pdf andPart I Unified Rate Review Data Template Dupficataxlsm have been attached to the filing and to this piece of amendment correspondence,

Changed Items:

No Form Schedule Items Changed.

No Rate Schedule Items Changed.

Supporting_D_o<:lJment Scheduleltern.~!l~ng~. __

Satisfied -Item: ____Ul1ified Rate Review TemplateComments:

Attachment(s):

Previous Version

Satisfied - Item:

Comments:

Attachment(s):

Part I Unified Rate Review Data Template Duplicate.xlsm

Part I Unified Rate Review Data Template.pdf- .. '" ._ ...•...•.._._~---'--... '---. ... -.-".,-.~~-~,-.", ...~.:,--,- .

-_.. ,'~~~-"-'-":"":';'.--._-

_Utiijeft'BfltiiReview Template

.. PDF Pipeline forSERFF TrockiiJg NumberCELT-129184888 Generated 09/12/2013 06:03 PM

SERFF Tracking #: CELT-129184888 State Tracking #: 259755 Company Tracking #: 61836WA001-RATE

State: Wl!shlngton t=l1Ing Company: Coordinated Care Corporation.TOI/Sub·TO': HOrg0211ndlviduai Health Orgenlzallons - Health Maintenance (HMO)IHOrg021,005C Individual - Other

Product Name: AmbetterProject Name/Number: /61836WA001 wRate

Note To Filer

Created By:

Nikki Meador on 09/03/2013 03:20 PM

Last Edited By:

Nikki Meador

Submitted On:

09/03/2013 03:22 PM

SUbJect:

Part I Requirement

Comments:

As per our General Filing Instructions requirements: You must name the Part I PDF file "Part I Unified Rate Review DataTempl"te:pdf'" and the Excel file must be written as "Part I Unified Rate Review Data Template Duplicate,xls ", Please submitan Amendment within the next 24 hours to correct this error so we niay accept your filing for review with the analysts &actuaries.

If you have any questions please cali the RF help desk at 360-725-7111.

PDF Plpa/lne ,or SERFF Traeldng Number CELT-129184888 Generaled 0911212013 06:03 PM

SEERFF Tracking #: CELT-129184888 State Tracking #: 259755 Company Tracking #: 61836WA001~RA TE

Stat91 Washington Filing Company: Coordinated C,are Corporation

TOVSub~TOI: HOrg021 IndIvidual Health OrganIzations ~ Nealth MaIntenance (HMO)/HOrg02/.006C Individual- OtherProduct Name: Ambetter

Project Name/Number: 161836WA001¥Rate

Reviewer Note

Created By:

Kelll Armfield on 09/12/2013 04:33 PM

SUbject:

Control Sheet

Comments:

See Attached

PDF Pipeline forSERFF Tracking Number CELT-129184888 Genera/od09/1212013 06:03 PM

Binder Control Sheet

Carrier: Coordinated Care

Market: Individual-Inside Exchange Only

Binder 259739 KelliForm(s) 259756 I Linda

259757259758

Rate 1259755 ILichiouNetwork

State 1D# ControlPerson

Binder ISERFF Status IControl Sheet l<ist\ Received Date IRespond by DateObjection Updated on (AS)Ready?

YINi Complete i

09/04/2013 09/01/2013Filed 09/04/2013 09/01/2013

Rled I 09/04/2013 09/01/2013

1~;!JI.;.'7fl Binder Anaiyst Only I

'This filing was filed per company certification. Please see notes in the r.te filing (state tracker ID 259755).

SERFF Trocking #: CELT-129184888 State Trocking#: 259755 Company Tracking #: 81836WAOOI-RATE

State: Washington Fillng Company: Coordinated Care CorporationTOI/Sub-TOJ: NOrgO?1 IndlvfdualHealth OrganIzations ~ Health Maintenance (HMO)/HOrg02/.005G IndivIdual ~ OtherProduct Name: AmbetterProject Name/Number; 161836WA001-Rate

. Reviewer Note

CreatedBy:

Kelli Armfield on 09/12/2013 04:32 PM

Subject:

Rate Request Summary

Comments:

See attached

PDF Plpaline for SERFF Tracking Number CELT-129184888 Generated 09/1212013 06:03 PM

AttachmentB

SERFF Tracking#: MLWA-129181353 State Tracklng#: 259759 Company Tracking #; 8-28 84481WA003 RATE

State: . Washington Flflng Company: Molina Healthcare of Washington, Inc.

TO'ISub~ TOI: Horg021 Individual Health Organizations ~ Health Ma'ntenance (HMO)/Norg02/.005e Individual w OtherProduct Name: MHW01012014- Rate

Project NamelN"!mber: Bw 28 RatelO03

Filing at a GlanceCompany:Product Name:State:TOI:Sub-TOI:Filing Type:Date Submitted:SERFF Tr Num:SERFF Status:State Tr Num:State Status:Co Tr Num:

ImplementationDate Requested:Author(s):Reviewer(s):Disposition Date:Disposition Status:·Implementation Date:


Molina Healthcare of Washington, Inc.MHW01 012014- RateWashin'gton

HOrg021lndi.vidual Health Organizations -Health Maintenance (HMO)HOrg021.005C Individual - OtherRate09/01/2013MLWA-129181353Closed-Filed259759Filed8-28 84481 WA003 RATE

01/01/2014

. Gretchen GillisLichiou Lee (primary)09/04/2013Filed01/01/2014

PDF Plpelina for SERFF Tracking Number MLWA-129181353 Generated 091101201304:11 PM

SERFF Tracklng#: MLWA-1291B1353 Stato Tracklng#: 259759 Company Trocklng #: B-28 B44B1WA003 RATE

State: WashIngton FlI1ng Company: Molina Healthoars of Was~/ngton, Ina.TOUSub~TOI: HOrg0211ndlvJdual Health Organizations w HeaHh MaIntenance (HMO)IHOrg021.005C Individual - Other

Product Name: MHW01012014- Rate

. Project N8me/Number: 8~28 RatelO03

General InformationProject Name: 8-28 Rate

Project Number: 003Requested Filing Mode:,Heview & ApprovalExplanation for Combination/Other:

Submission Type: New SubmissionOverall Rate impact:

Deemer Date:Submitted By: Gretchen Gillis

PPACA Notes: null


Filing Description:

For Public Rate Filing

Molina Gold Plan - AV 0.782Molina Silver Plan- AV 0.682

New product" 0% benefit changes

Company and ContactFiling Contact Information

Gretchen Gillis, Administrative AssistantPO Box 4004

Bothell, WA 98041

Status of Filing in' Domicile:

Date Approved in Domicile:

Domicile Status Comments:Market Type: Individual

Individual Market Type: individualFiling Statys Changed: 09/04/2013State Status Changed: 09/04/2013Created By: Gretchen Gillis

Corresponding Filing Tracking Number:

PPACA: Non-Grandfathered Immed Mkt.Reforms

Exchange only,

gretchen,[email protected]

800-869-7175 [Phone] 144046[Ext]

425-424-1168 [FAXj

Filing Company InformationMolina Healthcare of Washington,Inc,

PO Box 4004Bothell, WA 98041-4004

(800) 869-7175 ext.142646[Phone]


Retaliatory?

Fee Explanation:

State Specific

CoCode: 96270Group 'Code: 96270

'Group Name:FEIN Number: 91-1284790

State of Dom'icife: Washington

Company Type: HMO

State 10 Number: 91-1284790

PDF Plpoline forSERFF Tracking Numbor MLWA-1291B1353 Generated 091101201304:11 PM

SERFF Tracking #: MLWA-129181353 Stata Tracking #: 259759 Company Tracking #: 8-28 84481WA003 RATE

State:Tal/Sub-Tal:

Product Name:Project NttmelNumber:

Washington Filing Company: MoUna Healthcare of WashIngton. Inc.110rg021 Individual Health Organizations ~ Health Maintenance (HMO)/HOrg02/.005C Individual· OtherMHWQ1012014- Rate

8-28 Rate/003

If you are filing a Healthcare or Disability filing, is the Co Tracking # field populated on the General Information Tab? If no,your filing will be rejected. (yes/no): YesForm Tab Only - Are the Form # and Form Description fields populated corresponding to the attached form? (yes/no): YesIf your are submitting a File and Use product, have you populated the Implementation Date fieid? (yes/no): Yes

, .

PDP Pipelinf1 forSERFF Trao/((ng NumberMLWA·1"29181353 Generated 09/1012013 04:11 PM

•.. _.._--- .._.-_._--- ._---_._-.._ -_. -----_."SERFF Tracking #:

StiJ.te:TOUSub~T01;

Product Name:


A1LVVA-129181353 State Tracking #: 2!i9759 Company Tracking #: 8-28 84481VVAOO3 RATE

Correspondence Summaryo..l1>RQ$.ifu:lm;_...~..._.._ .'

Status _ .c~lcre..te<! By

Filed 'Lichiou Lee'

-_._,---_.__.•,,Created On

"'_.;-~-~----..' ..._...•

':09/04/2013" ._-,-_.----_..

--~~,-_._ ..-.--

iDate Submitted------·-------··-··"r'··- "-'

:09/04/2013

f'mngN9.le.S~ ...Subject

Rate Request Decision

Rate Requ~t~llm1"£1"ry

Control Sheet

__~No.!":rYl'eIReviewer Note

---:;e~~werNotet nO

[Reviewer Note

..<::r'eated By

.Kelll Armfield- ..-_.....,,""_....-"'_...•_.-..,-

'Kelli Annfield

Katie Goring .

!Created On..··-··--i-----10911012013

, •• _,-.0" •.•~; '__""_.'"

109110/2013

,09/0412013

Date Submitted

PDF Pipeline for SERFF Tracking Number MLWA-129181353 Generated 09/1012013 04:11 PM

SERFF Tracking #: MLWA-129181353 State Tracking#: 259759 Company Tracking #: 8-28 84481WAOO3 RAIE

State:TOlISuIrTO/:

Product Name:


Disposition'

WaShington Filing Company: Mofina Healthca:re of Washington, Inc.

HOrg0211ndividua/ Health OrganiZations - Health Maintenance (HMO)/HOrg021.005C Individual - otherMHW01012014- Rate8-28 RaIeIOO3

Disposition Date: 09/0412013

Implementation Date: 01/0112014

Status: Filed



Comment: This filing is filed as the rates are the same as previously.submitted under the state tracker ID 255781. The previous filing was disapproved solely due to thenetwork issues. The network issues have been resolved and the company has certified that the rate schedules and supporting dOcuments are the same as those filed

under the state tracker ID 255781 (except for new HIOS product and plan IDs).

Rate data does NOT'apply to filing.

SChedule

Suppo'!i.'1l1 Document

;~lIep()rtingDocument

'Sue.eorting Document

~lIpeortingDocument

'SlIPeorting.Document

;~.lIf'-"-0rtingDocument

Supporting Document

'Supporting Document

SlIPporting Document

Supporting Document

Supporting Document

Supporting Document

Supporting Document

SChedule Item Schedule Item Status.. - .. . .-. --, ..... __.... _--

Actuarial Memorandum and Certifications

Consumer Disclos.ure.!"orm Descriptions

Unified Rate Reviev,{.Template

WAC 284-43-945

WAC 284-43-930

Citation Documents

WASupplemental Actuarial Certification

Individual Non Grandfathered Health Plan (Poo!) Rate

Filing Checklist

Rate Schedule Duplicate

SRRT

Molina Annual Statements Exhibits

Molina AV PDF's

Molina Rate Filing Responses to OIC

PDF Pipeline for SERFF TraCking Number MLWA-'i29181353 Generated 0911012013 04:11 PM

Public Access

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Washington Filing Company; Malina HeaJthcare of lM2shington,. Inc.

HOrg02llndMduaJ Health Organizations - H~alth Maintenance (HMO)/HOrg02.1.005C Jndividual- Other

MHW01012014- Rate

8-28 RatelO03

--_._ _-_ .

SERFF Tracking #: .

State:TOf/Sub-TOI:

Product Name:

Project'NameINumber.

MLWA-129181353 state Tf3cking#: 259759 Company Tracking#:

.._.__•..__..8·28 84481WAQ03 RATE

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PDF Pipeline for S£RFF Tracking Number MLWA-129181353 Generated 091101201304:11 PM

SERFF Tracking #: MLWA-129181353 Stata Tracking #: 259759 Company Tracking #: Bw 28 84481WA003 RATE

stato:TOI/Sub-TOI:Product Name:Project Name/Number:

Washington FlUng Comp~ny.. Molina Hea/thcare of Washington. Inc.HOrg02/lndJvldual Health Organizations -Health Mafntenance (HMO)/HOrg02f.O05C Indlvldual- OtherMHW01012014- Rato8-28 Rato/003

Reviewer Note

Created By:

Kelli Armfield on 09/10/2013 02:46 PM

Subject:

Rate Request Decision

Comments:

See Attached

PDF PIp.,lne for SERFF Trac/<Ing Number MLWA-129181353 Generated 09/1012013 04:11 PM

Attachment C

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SERFF Tracking #: PBCC·129005550 Stato Tracking #: 254695 Company Tracking #: PBCWA INDIVIDUAL 01012014

State: WashIngton Filing Company: Premera Blue CrossTOI/Sub-TOI: H1611ndlvidual Health ~ Major MedlcaVH161.00SA Individual w Preferred Provider (PPO)Product Name: PBCWA IndIvIdual 0101201~Projoct Name/Numbe" PBCWA Individual 01012014/PBCI(VA IndlvldualOl012014

Filing at a GlanceCompany:Product Name:State:TOI:Sub·TOI:Filing Type:

. Date Submitted:

SERFF Tr Num:SERFF Status:State Tr Num:State Status:CoTr Num:

ImplementationDate Requested:Author(s):

Reviewer(s):Disposition Date:Olsposition .Status:Implementation Date:


Premera Blue CrossPBCWA Individual 01012014WashingtonH1611ndividual Health· Major MedicalH16L005A IndiVidual· Preferred Provider (PPO)Rate04/29/2013PBCC-129005550Closed-Filed254695Filed.PBCWA INDIVIDUAL 01012014

01/01/2014

Chunnan Wang, Tara Nichols, Ryan Templin, Julie Cooper, Hiu-Wan Ko, Yeni Son, CarlLaviolette, Daniel NessLichiou Lee (primary)07/31/2013Filed01/01/2014

PDF Plpehne for SERFF Tmc~'ng Numb.r PBCG-129005550 Generated 08/01/2013 05:12 PM

SERFF Tracking #: PBCC~129005550 State- Tracking #: 254695 Comp~nyTrackfng #: P89WA INDIVIDUAL 01012014

State; WashIngton Finng Company: Premera Blue Cross

rOVSub-rOI:. H1611ndivldual Health· Major Medical/H161.005A IndiVidual· preferred Provider (PPO) .

Product Name: PBCWA Individual 01012014

Pr%~~ct Name/Number:.· PBCWA Individual 01012014/PBCWA Individual 01012014

General InformationProject Name: PBCWA Individual 01012014Project Number: PBCWA Individual 01012014Requested Filing Mode: Review & ApprovalExplanation for CombinationlOther:Submission Type: New SUbmissionOverall Rate Impact:

Deemer Date:Submitted By: J'ulie Cooper

PPACA Notes: null


Status of Filing in Domicile: AuthorizedDate Approved in Domicile:Domicile Status Comments:Market Type: IndividualIndividual Market Type: IndividualFiling Status Changed: 0713112013State Status Changed: 0713112013Created By: Juiie CooperCorresponding Filing Tracking Number: PBCC128966313"PBCC-128977699, PBCC·128971348, PBCC128970893,PBCC-128971402, PBCC·128966373,PBCC128977156,PBCC-12a966377,PBCC-128966376

PPACA: Non-Grandfathered Immed Mkt Reforms

Exchange and Outside Market

Filing Description:This filing is for new products to comply With the ACA regulations. Since these are new products there is no benefit change.

This filing is for· Premera.Blue Cross Individual plans to be sold in and out of the exchange. This filing also includes Multi Stateplans to be solei in the exchange, The corresponding form filing tracking' nubmers are PBCC-128966313, PBCC· .128977699,PBCG-128971348,PBCC-128970893,PBCC-128971402, PBCC-128966373,PBCC-128977156, PBCC128966377,PBCC-128966376.

Below are the Names, Metal Levels and Actuarial Values for each new plan effective 111/2014.Premera Blue Cross Preferred Gold 500 Gold 0.810Premera Blue Cross Preferred Gold 1000 Gold 0.786Premera Blue Cross Preferred Gold 1500 Gold 0,781Premera Blue Cross Preferred Silver 2000 Silver 0.718Premera Blue cross Preferred Silver 2500 Silver 0.712Premera Blue Cross Preferred Silver 3000 Silver 0.702Premera Biue Cross Preferred Silver 2500 HSA Silver 0.684Premera Blue Cross Preferred Bronze 5500 Bronze 0,616Premera Blue Cross Preferred Bronze 6400 Bronze 0.620Premera Blue Cross Preferred Bronte 3850 HSA Bronze 0.619Premera Blue Cross Preferred Bronze 5250 HSA Bronze 0.620 .Premera Blue Cross Preferred Gold 500 with KidsDental Gold 0.810Premera Blue Cross Preferred Gold 1000 with KidsDental Gold 0.786Premera Blue Cross Preferred Gold 1500wlth KidsDental Gold 0.781Premera Blue Cross Preferred Silver 2000 with KidsDental Silver 0.718Premera Blue Cross Preferred Silver 2500 with KidsDental Silver 0.712Premera Blue Cross Preferred Silver 3000 with KidsDental Silver 0.702Premera Blue Cross Preferred Silver 2500 HSA with KidsDental Silver 0.684Premera Blue:Cress Preferred Bronze 5500 with KidsDental Bronze 0.616

PDF Plpeltne for SERFF Tracking NumberPBCC-129005550 Generated 0810112013 05:12PM

SERFFTrackfng#: PBCC-129005550 Stat. Trackfng#: 254695 Company Tracking #: PBCWA INDIVIDUAL 01012014

State: Washington Filing Company: Premera Blue Cross

TOVSub-Tal: Hl61'ndlvldual Hca"h - Major Medica11H161.005A IndiVIdua/- Prefarred Provider (PPO)Product Name: PBCWA Individual 01012014Project NamelNumbor: PBCWA Individual010120141PBCWA fndividual01012014

Premera Blue Cross Preferred Bronze 6400 with KidsDental Bronze 0.620Premera Blue Cross Preferred Bronze 3850 HSA with KidsDehtal Bronze 0.619Premera Blue Cross Preferred Bronze 5250 HSA with KidsDental Bronze 0.620 .

'Premera Blue Cross Bronze Group Conversion with KidsDental Bronze 0.620Premera Blue Cross Preferred Gold 500 Package V Gold 0.810Premera Blue Cross Preferred Gold 1000 Package V Gold 0.786 ,Premera Blue Cross Preferred Gold 1500 Package V Gold 0.781Premera Blue Cross Preferred Silver 2000 Package V Silver 0.718'Premera Blue Cross Preferred Silver 2500 Package V Silver 0.712Premera Blue Cross Preferred Silver 3000 Package V Silver 0.702Premera Blue Cross Preferred Silver 2500 HSA Package V Silver 0.684Premera Blue Cross Preferred Bronze 5500 Package V Bronze 0.616

, Premera Biue Cross Preferred Bronze 6400 Package V Bronze 0.620Premera Blue Cross Preferred Bronze 3850 HSA Package V Bronze 0.619Premera Blue Cross Preferred Bronze 5250 HSA Package V Bronze 0.620Multi State Plan Blue Cross Preferred Gold 500 Gold 0.810Multi State Plan Blue Cross Preferred Gold 1000 Gold 0.786Multi State Plan Blue Cross Preferred Gold 1500 Gold 0.781Multi State Plan Blue Cross Preferred Silver2000 Silver 0.718Multi State Plan Blue Cross Preferred Silver 2500 Silver 0.712MUlti State Plan Blue Cross Preferred Silver 3000 Silver 0.702Multi State Plan Blue Cross Preferred Silver 2500 HSA Silver 0.684Multi State Plan Blue Cross Preferred Bronze 5500 Bronze 0.616Multi State Plan Blue Cross Preferred Bronze 6400 Bronze 0.620Muiti State Plan Blue Cross Preferred Bronze 3850 HSA Bronze 0.619Multi State Plan Blue Cross Preferred Bronze 5250 HSA Bronze 0.620

Company and ContactFiling Contact InformationJulie Cooper, Actuarial ManagerPO Box 327

,MS 395Seattle, WA 98111-0327

Filing Company InformationPremera B.1ue' CrossPO Box 327MS 390Seattle, WA 98111-0327(425) 918-5834 ext. [Phone]

[email protected] [Phone]

CoCode: 47570Group Code: 962Group Name:FEIN Number: 91-0499247

State of Domicile: WashingtonCompany Type: HospitalMedical Service CorporationState 10 Number: 204

._---_.------_ .•_.. '---_..__._---.-.

,Filing FeesFee Required?

Reteliatory?

Fee Explanation:

No

No

PDF Pipeline lor SERFF Tmclrlng Number PBCC-129005550 Generated 08(011201305:,12 PM

SERFF Tracking II: PBCC·129005550 Stata Tracking II: 254695 Company Tracking#: PBCWA INDIVIDUAL 01012014

State:· Washington Filing Company: Premors Blue CfossTOVSub·TOI: H1611ndlvldual Heafth· Mejor MedlcaVH161,005A Individual· Preferred Provider (PPOj

Product Name: PBOWA Ind/vldualOl012014

, Project Nama/Number: 'PBCWA Indivlduai 010120141PBCWA IndiVIdual 01012014

State SpecificIf you are filing a Healthcare or Disability filing, is the Co Tracking # field populated on the General Information Tab? If no,your fillng'wlII be rejected. (yes/no): yesForm Tab Only - Are the Form # and Form Description fields populated corresponding to the attached form? (yes/no): yesIf your are submitting a File and Use product, have you populated the Implementation Date field? (yes/no): yes

PDF Pipeline for SERFF Tracking Number PBCG-129005550 Generated 081011201305:12 PM .

._-~_...._-_.-- .._-----_.._----_ .._--Washington riOng Company:17161 lndMd,-!aJ Health - Major MedicaJIH16J.O05A Individual - Preferred Provider (PPO)PBCWA Individuaf01012014

PBCWA Individual 010120141PBCWA InalViduaJ 01012014

Premera Blue Cross

SERFF Tracking #:

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PBCC-12900555D State Tracking #; 254895 Company TracfPnrJ #: PBCWA INDIVIDUAL 01012014

--_.••-_._. _.__._-

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Lichiou Lee

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07/24/2013

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05/09/2013

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07/15/2013

05120/2013

_Amendmen~Schedule Schedule Item Name Createcll3.Y _ Created On D",te Submitted

Rate Rates 2014 Tara Nichols 07i0312013 0710312013

SuPportin9 Actuarial Memorandum and Certifications Tara Nichols 07/0312013 07/0312013

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SuPportin9 Unified Rate Review Template Tara Nichols 0710312013 07/0312013

Document

Supporting Filing Exhibits Tara Nichols 07/0312013 07/0312013Dpcument

Supporting Rate Table Template Tara Nichols 07/0312013 07/0312013Document

PDF Pipeline for SERFF Tracking Number PBCe-129005550,G$nerated 0810112013 05:12 PM

SERFF Tracking #: PBCC-129005550 State Tracking #; 254695 Company Tracking #: PBCWA INDIVIDUAL 01012014

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PDF Pipeline for SERFF Tracking Number PBCG-129005550 Generated 08101/2013 05.-12 PM

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....._._----_._.._- ..__._----_._ ..._---Washitigton Filing Company:

H161 Individual Health - Major MeatcalJH161.00SA Individui3l- Preferred Provider (PPO)

PBCWA Individual 01012014

PBCWA Individual 010120141PBCWA Individual 01012014

SERFF Tracking #:

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Premera Blue Cross

PBCWA INDIVIDUAL 01012014

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PDF Pipeline for SERFF Tracking Number PBCC-129005550 Generated 08101/2013 65:12 PM

SERFF Tracking #: PBCG-129005550 State Tracking #: 254695 Company Tracking #: PBCWA INDNIDUAL 01012014

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Premera Blue Cross

Disposition Date: 07/31/2013

Implementation Date: 01/01/2014

Status: Filed



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PDF Pipeline for SERFF Tracking Number PBCC-129005550 Generated 08101/201305:12 PM

SERFF Tracking #: PBce-129005550 . State Tracking #: 254695 Company Tracking #; PBCWA INDIVIDUAL 01012014

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H15/ IncfNidual Health - Major Me<flC81lH16J.OOSA lOON/dual - Preferred Provider(PPO)

PBCWA Individual 01012014

PBCWA lndMdual 01012014PBCWA InoNidual 01012014

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SERFF Tracking #: PBCG-129005550 State Tracking #; 254695 Company TraCking #: PBCWA INDIVIDUAL 01012014

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Project NameINumber:

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PBCWA Individual G10120141PBCWA IndMdual-01012014

Premera Blue Cross

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PDF Pipeline for SERFFTracking Number PBCG-129005550 Generated 0810112013 05:12 PM

Attachment D

SERFF Tracking #: RGWA·129010583 Stata Track/ng #: 254781

State: Washington Filing Company:

TOIISub.TOI:· H16/lndivldual Health· Major ModlcaVH161.005C Individual· Other

Product Name: 2014 BrldgeSpan Exchange Rate FlUngProject Name/Number: /

Company Tracking #: WA 0/C#500823

BrldgfJSpan Health Company

Filing at a GlanceCompany:Product Name:State: .

Tal:SUb-Tal:Filing Type:Date Submitted:SERFF Tr Num:SERFF Status:State Tr Num:State Status:CoTr Num:

ImplementationDate Requested:Author(s):

Reviewer(s):Disposition Date:Disposition Status:Implementation Date:


BridgeSpan Heaith Company2014 BrldgeSpan Exchange Rate FilingWashingtonH1611ndividual Health - Major MedicalH161.005C individual - OtherRate05/0112013 .RGWA-129010583Closed-Flied254781

. FiledWA OIC# 500823

01/01/2014

Paul Harmon, Mikenzie Matteson, Carol Tashiro, Brett. Miller, Carolyn Ranck, HeatherHokamp, Christopher Coulter, Daniel Boeder, Evan Baker. Patrick JouShiraz Jetha (primary)07/31/2013Filed01/01/2014

PDF Pipeline for SERFF Tracking Number RGWA·129010683 Generated 07131/J013 04:18 PM

SERFFTracklng#: RGWA-129010583 Stat. Tracklng#: 254781

State: Washington Filing Company:

TOUSub..TOI: H1611ndlvldual Health ~ Major MedlcaflH16/. 005C Individual w OtherProduct Name: 2014 BrldgBSpan Exchange Rate Filing

Project Name/Number: I

Company Tracking #: WA O/C# 500823

BrldgeSpan Hl1alth Company

General InformationProject Name:Project Number:Requested Filing Mode: Review & ApprovalExplanation for Combination/Other:Submission Type: New SubmissionOverall Rate Jmpac!:

Deemer Date:Submitted By: Paul Harmon

PPACA Notes: null


Filing Description:

BridgeSpan Health CompanyNew Product FilingEffective January 1, 2014

Status of Filing in Domicile:Dete Approved in Domicile:Domicile Stetus Comments:Merkel Type: IndividualIndividual Markel Type: IndividualFiling Status Changed: 07/31/2013

State Status Changed: 07/29/2013

Created By: Carol TashiroCorresponding Filing Tracking Number:

PPACA: Non-Grandfathered Imm<ld Mkt R<lforms

. Exchange only

This is a new product filing for products in the Exchange. BridgeSpan is offering the following 4 plans, with correspondingmetal level and actuarial value:1. BridgeSpan Gold, AV 0.7822. BridgeSpan Silver, AV 0.691

· 3. BridgeSpan Bronze HSA, AV 0.5894. BridgeSpan Catastrophic, AVO.621

Please see the file "Rate Filing Checklist" in the Supporting Documents folder for the location of all elements required in this.filing.

CoCode: 95303Group Code:Group Name:FEIN Number: 87-0388069

·Company and ContactFiling Contact InformationPaul Harmon, Assistant Director, Actuarial [email protected]

·Pricing200 SW Market SI. 503-225-5144 [Phone]MSE8APortland, OR 9720f

Filing Company InformationBridgeSpan Health Company28~0 E. Cottonwood Pkwy·Salt Lake City, UT 84121(801) 333-2100 ext. [Phone]

State of Domicile: UtahCompany Type:State tD Number:

PDF Pipeline forS£RFF Tracking NurhberRGWA-129010583 Generated 07f.J112013 04:18 PM

SERFF Track/ng #: RGWA·129010583 Stata Tracking #: 254781

Ii"

State: Washington Piling Company:

TOUSub·T01: Hl6/lndlvidual Haaffh· Major Medlcal/HI61.005C Individual· OtherProduct Name: 2014 BrldgeSpan Exohange Rate Filing .

Project Name/Number: /

Company Tracking #: WA OIC# 500823

BrfdgeSpan Health Company


Retaliatory?

Fee Explanation:

NoNo

State SpecificIf you are filing a Healthcar<;> or Disability filing,. is the Co Tracking # field populated on the Generai Information Tab? If no,

.your filing will be rejected. (yes/no): YesForm Tab Only· Are the Form # and Form Description fields populated 'corresponding to the attached form? (yes/no): YesIf your are SUbmitting a File and Use product, have you populated the Implementation Date field? (yes/no): Yes

FDF Pipeline for SERFF TmckingNumber RGWA-129010583 Genarilled 07131/2013 04:18 PM

SERFF Tracking #: RGWA-129010583 State Tracking #: 254781 Company Tracking#: WA OICll500823

State:

TOI/Su~TO/:

Product Name:


-_.. -,..'~._--.,~--"Washington Filing Company:H161 Individual Health - Major Me(/icaVH16l.005C Individual - other

2014 BridgeSpan Exchange Rate RfingI

~---....•........BridgeSpan Health Company

Correspondence Summary.Ols..PJ~sl.ti..Q.tI.$..~.... . __ ._ .

. StattJll •." Created By.. . .

Filed -Shiraz Jetha

Fil~__.. _ .... :Shiraz Jeth"...... __.

.........••._..._--.Created·On

07/3112013

0712912013

Date Submitted

0713112013--- _.._..-~ ..

0712912013__--c.

Objection Letters and Response Letters

()~j<;><:!!'J.!l L.,et,t."rs .

§It<i!~__ ... ~~..r:~ted By ..•.••·Cr~.ecJ0n

Active ·Katie Goring ':07/2612013

_~~sE§~~~,._

Active Katie Goring 0712312013

Sus~n.~.". .•...

Active Shiraz Jetha 07/09/2013

Susp~n~~,.

Active Shiraz Jetha 07/06/2013

Suspense

Active Shiraz Jetha '0612812013

Suspen~e ...

Active Shiraz Jetha 0612012013Suspense

Active Shiraz Jetha 05/1712013

Suspense

Date Submitted",-------

07126/2013

0712312013

07/09/2013

07/06/2013

0612812013

0612012013

0511712013

Response le.!t<;>f.l'..•....

Responded.~y__..•. ~re.atedOn

Carolyn Ranck 07/2612013

Carolyn Ranck 0712412013

.'"~'._-_.-_.--.,.. --


._.._-



--_.~---_. - .__ ..


Carolyn Ranck 0611112013

__-+'iD~e. Submitted'

i0712612013

., ·------·---·---T·-

'07124/2013

.""~,,-,._----'.'07/1012013

·']0711 012013

07/0212013

0612512013

0611112013

AmendmentsSchedule

Rate

Schedule Item Name

2014 Exchange Rates

Created By

Paul Harmon

Created On

07/3012013

Date Submitted

07/3012013

PDF Pipeline for SERFF Tracla"ng Number RGWA-129010583 Generated 07/31/201304:18 PM

SERFF Tracking #: RGWA-129010583 State Tracking #: 254781 Company Ttacking #: WA OIC# 500823

Slate:

TOllSub-TOI:

Product Name.#


waShington RUng Company:

H16/ Individual Health - Major MedicaJlH16LOO5C IndMdual - other'

2014 BridgeSPaJ? Exchange Rate Rling

I

BridgeSpan Health Company

Amendmeotsc....

Schedu!e Jlichedule Item N§lIll.e ....

[Paul Harmon

._., _.' _.__ .....•-._...... ,,_...•._..

'Paul Harmon

Supporting

Document

Supporting

Document

Supporting

:Document

Supporting

Document

Supporting

Document

Supporting

Document

Supporting

Document

Supporting

Document

Rate

Supporting

Document

'Actuarial Memorandum and Certifications

'Response to Objection 7.26.2013

1SSH Amendment 7.30.2013

Response to Note to Filer 7.13.2013

:Supporting Documentation

'Senefrt Component Summaries


.Unified Rate Review Template

20.14 Exchange Rates

Supporting Documentation

-~-_.._-----, -- -,",--

. . ICreated By. -- 1.--,"---,-~,_. -_.[Paul Harmon

~-_.. - .._._-

:CarolynRanckI

Heather Hokamp

'Christopher Coulter

Christopher Coulter

'Christopher Coutter

.Mikenzie Matteson

.Mikenzie Matteson

.)':;r~~~<;I..9.E._ '.07/3012013

,07/30/2013

07/3012013

07/1912013

07/0512013

06/1412013

.0511 012013

0511012013

0510812013

05/0812013 .

'Date Submitted

07/3012013

07/3012013

07/3012013

07/1912013

07/0512013

0612112013

0511312013

0511312013

. 05/1012013

05/10/2013

Filing NQte$ ..Subject

OIC Request on Rx Adjustment

Note to Filer 7.13.2013'

Response to Objections Received

Rate Schedule Tab

'Note Type

Note To Reviewer

Note To ReVIewer

Note To Filer

Note To Filer

Created By Cr"ated On Date Submitt"d

Cerolyn Ranck . 0712512013 07/2512013

Cerolyn Ranck· 0711912013 07/1912013

Shiraz Jetha 071131201.3 0711312013

Shiraz Jetha 0710812013 07108/2013

PDF Pipeline for SERFF Tracking Number RGWA-129010583 Generated 07/3112013 04:18 PM

SERFF Tracking #: RGWA-129010583 State Tracking #: 254781 Company Tracking ft.: WA OIC# 500823

'State:

TOUSub-TOI:

Product Name:Project Name/Number:

Washington Rling Company:H16/lncflViduaJ Health - Major MedicallH16LOO5C Individual - Other

2014 BridgeSpan Exchange Rate Filing

/


,07/0512013 0710512013..__.._ - -=---_. ..'

Date Submitted

0512412013 .,,_._--------

0512212013....._--_._ ...

06/12/2013.....'._......__.__..-,_._.-,.

0611212013_.•. _.__._._...

0713112013

07/3112013

0713112013

05/2412013.......-_.....,--_.,.,.

0512212013

06/1212013

06/1212013.-_.,," ._-,.-

P§/1112013 .__ .....06/11/201.3'--__.

'Created On

.0713012013

iKelii Armfield

'Kelli Armfield

'Shiraz Jetha

_l~biraz Jetha

__-fic",a",'ro""I¥I1RanCk

. iCarolyn Ranck.._-------t---.,...--..-." ,

iShiraz Jetha~-,._-~,iKelii Armfield

....__ iCre~dBy

!~b~~J."tha---.F,...__Ea.r"iyn Ranck,

Reviewer Note

Reviewer Note- '--'---'..._-.. -'.-

Note To Reviewer

Note To Reviewer

Note To Filer_._--".'"'

lII<>.te.,.y'~_.

Note To Filer

Note To Filer

Reviewer Note

Reviewer Note

·Note To RevieweriE?O [),,¥ Review Perio.d •.. _. _

'6()Day Review Period

:C2bj~~~n Extension

[f<"quest for Extension o~.()El,,'::tIo.n..

'Objection 4,----'." --, ,

·Control Sheet

"Rate Request Summaf)' .

~R~" ",,,quest Decision ... _..__~ __ .

Service Area Change - CI§li<.f.".l!':':t¥..

EUins.-N.otes ._.__ .

l~,!~j~ ..... -.---- ....-lAV Screenshots Urgent!,----_-."._.- ""--".-.... ,._,-._-..

PDF Pipeline for SERFF Tracking NumberRGWA-129010583 Generated 0713112013 04:18 PM

SERFFTracJdng#:· RGWA-129010583 State Tracking #: 254781 Company Tracking #: WA OICll500823

state:TOUSub-T01:

Product Name:


Disposition

washingtqn Rang Company:H16J Individual Health - Major Med;caJJH161.005C lndividual- Other

2014 BrfdgeSpan Exchange Rate Filing

/


Disposition Date: 07/3112013

Implementation Date: 01"/0112014

Status: Fiied



Comment:

Rate data does NOT apply to filing.

Schedule

iSupporting Document (revised)r- o .'---" •••••'",.",-",,, •••••,.'. -,.

~~"-PJ)ortingDocument

~uJlportingDocument

[Supporting Documen!.__... .. _

l~upporting Document

~.lJPportingDocument

~u'pporting Documentir!lvI~El.<lt

:Supporting Document

,~u_pportingDocument

§'lJpporting Document(r~vise<l)

Supporting Document

s.upporting Document

Supporting Document

Su·pporting Document

SupporJng Document (revised)

Schedule Item



.Actuarial MemQrandum and Certifications·


Actuarial Memorandum and Certifications-_._.._-~~-.

Actuarial Memorand·um and Certifications

Consun:~~Disc!?~~~e Form Descriptions

Consu~~~_i?J~.~~?~ure Form Descriptions

Consumer Disclosure Form Descriptions

Unified Rat"f<",vi"", Template


Unified Rate..f<..""i"w Template


Unified Rate "Review Template


Schedule Ite"" Status Public Access

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

PDF Pipeline for SERFF Tracking NumberRGWA-129010583 ~enerated07/31/2013 04:18 PM

,._--_._---,Washington Filing Company:H161 Individual Health - Major MedicaJlH16/.005C Individual - Other2014 BridgeSpan Exchange Rate Aling .

I

WA 010# 500823SERFF TTacking #:

State:TOlISub-TOI:

ProductName:


RGWA-129010583 State Tracking #: 254781 Company Tracking #:

BridgeSpan Health Company. "".-",---

Schedule

Supporting [)ocument

Supporting Do~.u"Il1~n_t__ ...

Supporting D()C:~Il1~rT!.__

Supporting D()cl;lll1~.nL_._

Supporting Docl1ntent"

Supporting Doc:.!!.men!1revis~J

Supporting Document. - -~_._,-.__....._,-, ~ .. ,- .

Supporting Docl1ll1e.n!.- .

Supporting Doc!!."!.~'2.t.i~~YLs~d)

Supporting Docl1.l1l~nt

Supporting DOc:I;lI11!!1! __

Supporting Docul11ent.

Supporting Docl1ll1ent(revised)

Supporting Docu.l11e.!1! .. , ..

Supporting Docl;lmentJrevised)

Supporting DoculTlent

Supporting Docl1rnEmt

Supporting Document

Supporting Docul1lent

Supporting Document


Supporting Document


Schedule Item

. ·r~.~~~~~~~~~;~,:mElntationiSupporting Documen~ion..;--".,_..._--,......_""..-,..• ,_.-.,. _.- -. .

J~uPP9.rtin~!l.0c:umentation .

'Supporting Documentation",.._._._--"..'_.•__ __ _----- -,,j~uPP9!!irT\J.[).9cumentation

, .. _~.,ne~.~.9~p'onentSummari~"

J!3El_n..,ril..~9ntp'onentSummaries,:!3erT~!itC:0.f11.po.nent Summaries

,45 CFR Subpart E OHP Requirements._j---------_.,-_.._- -, "_.....

'4!i.c:~BSu_bpart E OHP Requirements

·.4:!i..~£.R.!:,u~pa..rt E OHP Requirements

.45.CFF( Subpart E OHP Requirements

:F(e~E?ns.e to Objection 5.17.2013

Re~P?~Se_!oObjection 5.17.2013

F(~~E9.nseto Objection 6.20.2013

Re~pon,;e to Objection 6.20.2013 .

Resp.9.n~e to Objection 6.28.2013

Response to Objection 7.6.2013

Resp?nse to Objection 7.9.2013

Response to Note to Filer7.13.2013




Schedule Item Status.._----_ .._._"..~... Public Access

'Yes

Yes'

Yes

Yes

..Y~__. ~'_'Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

PDP Pipeline for SERFF Tracking Number RGWA-129010583 Generated 07/3112013 04:18 PM

SERFF Tracking #; RGWA-129010583 State Tracking #: 254781 Company Tracking #: WA OIC# 500823

____""_""0""".'"

State:TOVSulJ.TO/:

Product Name:

froject Name/Number:

Schedule

Washington Filing Company:

H1611ndividuaJ Health - MajorMedicaVH161.005C InaNiduaI - Olhar

2014 Bridge8pan Exchange Rate FQing.

I

Schedule Item,-~-.._.-.


Schedule Item Status. . Public Access

§':'PPCl'!ingI)Clcum"n_t _

,§uf'lJorting Document

i~"te(reV'ised)"'

!Rate

!Rate

!~~~.

iRate

'Rate

Res£onse te,.'?~tecti,?~ !:~ElfO!3

BSH Amendment 7.30.2013..._._.•._", ..,._,

2014 B<c.~"ns,l<3 Rates

2014 B<"b,,~Qe R,ates

2014 ~xchange Rates

2014. ~ch,,~!).eRates

2014 ~"h"ns,leRates

2014 EXchan!)e Rates

----,-,-- .',

Yes-,.._._-"_."._".. ~_.._- ._-..... _- -"'Yes

Yes

Yes

Yes

Yes

Yes

Yes

PDF Pipeline for SERFF Tracking Number RGWA-129010583 Generated 071311201-3 b4;18 PM

SERFF Tracking #: RGWA-129D1D583 State Tracking #: 2M78'1 Company Tracking #: WA 010# 500823

State:

TOVSub-TOI:Product Name:

Project NamelNumber:

Disposition

Waspington Filing Company:

H151lndividual Health - Major MedicaI/H16/.005C Individual- ~ther2014-.BridgeSpan Exchange Rate Filing

I


Disposition Date: 07/29/2013

Implementation bate: 01/01/2014

status: Filed

HHS Status: HHS ApproVed


Comment:

Rate data does NOT apply to filing.

Schedule

SUPP.o_rti."!L[)()<:ument (revised)

Sup~~~n9Q~c~ment

SuPP"rt.~l1J'-':J~Ellment

SUl3porti!'.9 Doc~ment

SupP.'?rti!'.!L[).o_cllment

Supp°rtil1gp~"ument

Supporting .[),,-c_ument (revised)

Supp°rtil1g.Document

SUPP"rtin9 pocument

SuPPortin9.[).ocllment (revised)

SuPportin9 Document

Supportin9.D°cument

Supporting Document

Supporting Document


Schedule Item

Actuarial Memorandum and Certifications...._, .'----"-,""'''''-''

:i\ctuarial Memoran~u_", and G.ertifrcations

'Actuarial Memorandum and Certifications

Actuarial Memorandum and Certifications.--'--~~-'~'---------"


Actuariai Memorandum and Certifications

Collsurner Disclosure F0:r!'Cles.criptions

Consumer Disclosure Form Descriptions

Consumer Disclosure Fonn Descriptions

Unifred Rate Review Temp'late.

. Unified Rate Review Template



. Unified Rate Review Template


Schedule Item Status Public Access-_. - _..•,..__ .._--_.-'Yes

'--~-T

Yes..---------..

:Yes.~·_·~·------i- -'

Yes

Yes

:Yes

Yes

Yes

"Yes

Yes

Yes

Yes

Yes

Yes

Yes

PDF Pipeline for SERFF TraCking Number RGWA-129010583 Generated 0713112013 04:18 PM

SERFF Tracking #: RGWA-I29010583 State Tracking #: 254781 Company Tracking fl.: .-.---_._. ---

WA DIC# 500823

State:TOl/Sub-TOt:Product Name:

project Name/Number:

Washington Rling Company:

H1611ndil(iduaJ Health - Major.MedicafIH16J.005C lndividual- Other

2014 BridgeSpan Exchange Rate Firmg

I


Schedule

~Supportin!t[),,£,umell.!- ... _. __._.Supporting Doc.l'rn.ent

Supportin~ DOCUITI"nt

Supportin~ DOCulll"nt

Supportin~Do"-urn,,.nt ..

Supportin~ Doc;l;!!Jl"."tJrevi"_,,dl

Supportin~ Document

Supporting Document

Supporting Docunlent(revis~)..

Supportin~ Document

Supporting Docu'llen.t

Supporting Document

Supporting Document(revised)

Supporting Document


Supporting Document

Supporting Document

Supporting Document

Supporting Document

Supporting Document


Supporting Document


Schedule Item,

.......__,S':'Pl'.5'rtinll..Documentalion .

__ ...ll>~pportingDocumentation __. _

[Supporting DocumentationT········"···,,",,···,,",·····,, -, -, .• ' •.-,,--_.

_l>~pportingDocumentation_. _

• oo_ ,~.':'Pl'().rting Documentation

__ .l~en~rt_c;omponentSumn:~ri:=

...@"'ll"fit Component Summ"ri:'S.

__ ._'§"'ll.efil C()mponent Summari:'S..

~~4_~E£RSubpart E QHP Res~r-",~"nts

,4?CFR Subpart E QHP Requi",ments

:45 CFR Subpart E QHP Requirements.-:~ .._._--- -- , , ~ ..__ ._,.- - -

45 Ci=R Subpart E QHP Requirements

.R""ponse to Objection 5.17.2013

R""flOnse to Objection 5.17:~~}_3 .

Response to Objection 6.20:201~

Response· to Objection 6.20.2013

..f\esponse to Objection 6.28.2013

Response to Objection 7.6.2013.

. Response to Objection 7.9.2013

Response to· Note to Fiier7.13.2013




Schedule Item Status Public Access

'yes---Yes

Yes

Yes

Yes

Yes

Yes _.. _. ._

Yes

Yes

Y<3S

Yes.'~---~._~---.-- ....'.

Yes

Yes

Yes .... ._

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes·

Yes

PDF Pipeline tor SERFF Tracking Numb.er RGWA-129010583 Generated 0713112013 04:18 PM

WA QIC# 500823

Bridgespan Health Company

Company Tracking #:

.- .._...._~-_.

254781State Tracking #:RGWA-129010583

....••..._~--_.Washington Filing Company: -

H16{ {ndMdua! Hea~h - Major MedicallH16f.(j()5C (ndividuaJ - Other2014 BridgeSpan Exchange Rate Filing

I

State:TOUSub-TOI:

ProductName:

Proje~Name/Number:

SERFF Tracking #:

Schedule Schedule Item Schedule Item Status Public Access."_...._--_.~.-.

~lJep()rtin9 .. [)0"unlel1t,- _

,SlJPportin9 Document ...

'Fffite (revised)

'Rate

'Rate

Rate

iRate

Rate

Response to Objecti<>.~.7..26.2013

BSH Amendment 7.30.2013

2014 Exch.".ngeR"tes.

2014 EXcl1ange.i'<at~..

2014 Exchal1~"i'<~es....

2014 Exci1ange Rat"s

2014 Exchal1\l" i'<ates

2014 Exch""\l."...i'<"'!es

Yes_...._..__..-"-, <"-"'--'----

Yes

Yes

Yes

Yes

Yes

'Yes .

Yes

PDF Pipeline for SERFF Tracking Number RGWA-129010583 Generated 07/31/2013 04:18 PM